CLINICAL

AND

RESEARCH

Am

REPORTS

BY

JEAN

Following G. SPAULDING,

Therapeutic M.D.,

AND

JESSE

0.

CAVENAR,

‘

Reports

Case 1. Ms. A, a 17-year-old unmarried girl. was raised in a large, religious southern family. She was the youngest of 10 children; both of her parents were greatly invested in her academic and social life. All of her siblings had attended college, and she feltpressure from both her parents and siblings to be more successful than they had been. The patient attempted to fulfill the aspirations that her family had for her. She was an honor student in high school, and because she excelled in one subject she was com-

JR.,

M.D.

petitively chosen to attend a long summer program in that field after her sophomore year of high school. This was the first time she had been away from home for an extended penot;I; she met her first boyfriend, fell in love, and became pregnant. She visited a sister in a northern city and obtained a therapeutic abortion without her parents’ knowledge. She returned to high school and functioned well throughout the year. The summer after her junior year she developed lethargy. malaise, and nausea with occasional vomiting. Thorough physical evaluation failed to reveal any organic cause for the symptoms. A short time later she complained of feeling bloated, excessive weight gain, and breast engorgement and tenderness. On the eve of the first anniversary of her therapeutic abortion, she experienced an overt psychosis

0002-953X/78/0003-0364$O.35

and

was

referred

for

psychiatric

care.

The mental status examination revealed marked regression, visual hallucinations, and psychotic thought processes. Ms. A had the delusion of being the Virgin Mary and having been impregnated by Satan or by God. She assumed the fetal position and moaned of her ‘sin. The regression was so severe that she had fecal incontinence and smeared the feces on herself and around the room. She had visual hallucinations of people growing fangs with which they could ‘punctune’ her. There were seizures characterized by hyperventilation and movements resembling coitus. The patient experienced intense paranoid ideation of attempted seduction by male attendants and at the same time made overt ‘

‘ ‘

‘

‘

attempts to seduce those same Psychological testing revealed

male attendants. a marked amount

of guilt

and a tendency to sexualize relationships. Treatment with an antipsychotic drug was begun, with good resolution of the psychotic behavior. She was able to attend school on the ward and functioned generally in a nonpsychotic manner. However, each time her menstrual period began, she rapidly regressed to psychotic behavior with fecal smearing and visual hallucinations. Gradually Ms. A became able to verbalize her concerns about the abortion. She clearly felt overwhelming guilt. Her strong religious beliefs led her to think that she had cornmitted an unforgivable sin. After a 5-month hospitalization, she returned to her usual level of functioning. The antipsychotic

The authors are with the Duke University Medical Center, where Dr. Spaulding is a resident in psychiatry and Dr. Cavenar is Associate Professor of Psychiatry; and the Durham Veterans Administration Hospital, 508 Fulton St., Durham, N.C. 27705, where Dr. Cayenar is Chief of Psychiatry. Address reprint requests to Dr. Cayenar.

364

1978

Abortion

The literature concerning therapeutic abortion suggests that there are few significant psychiatric sequelae of the procedure. Patt and associates (1) reported that therapeutic abortion has minimal or no emotional impact on women without a psychiatric history. Ewing and Rouse (2) concluded that ‘women without gross current psychiatric illness can usually take the procedure in stride” (p. 39). Osofsky and Osofsky (3) did follow-up studies on 250 healthy women who had meceived abortions and reported few psychological difficulties. Werman and Raft (4) studied over 120 women up to 14 months after abortion; they concluded that in only I patient could an emotional disturbance be directly attributed to the abortion. Lask (5) did a prospective study of women before abortion and 6 months afterward. He concluded that “in the majority of cases with adverse outcomes this was related to the patient’s environment since the operation rather than the termination” (p. 176). Our experience is at variance with those in the litemature; we have seen a number of patients who did have emotional difficulties after a therapeutic abortion. The purpose of this communication is to report two cases in which the patients clearly functioned well before the abortion and experienced psychoses precipitated by guilt over the abortion. We do not believe that environment or other factors contributed to the psychoses. Case

135:3, March

Washington, DC, Department of Health, Education, and Welfare Publication ADM 76-338, 1976, pp 383-406 6. David 0, Clark I, Voellen K: Lead and hyperactivity. Lancet 2:900, 1972 7. Werry iS, Aman MG: The reliability and diagnostic validity of the Physical and Neurological Examination for Soft Signs (PANESS). J Autism Child Schizo 6:253, 1976

Wolff PH. New York, Grune & Stratton, 1973. pp 55-77 3. Rutter M. Graham P. Yule W: A Neunopsychiatric Study in Childhood. Philadelphia, JB Lippincott Co. 1970 4. Adams RM, Kocsis ii, Estes RE: Soft neurological signs in learning-disabled children and controls. Am I Dis Child 128:6 14, 1974 5. Guy W: ECDEU Assessment Manual for Psychopharmacology.

Psychoses

J Psychiatry

medication

for a year. She further sequelae

was

stopped

is now completing of her illness.

after

she

college

had

functioned

with

well

no apparent

Case 2. Ms. B. a 24-year-old unmarried woman, was employed in a position of great responsibility. She became preg-

© 1978 American

Psychiatric

Association

Am

J Psychiatry

135:3, March

1978

CLINICAL

nant and obtained an abortion in her third month of gestation. Six months later, ‘at the time I would have had my baby,” she experienced insomnia, anorexia, agitation, and severe depression that necessitated psychiatric hospitalization. The mental status examination revealed profound depression and increased psychomotor activity. The patient paced constantly and had pressured speech. Her dress was inappropriate, and her makeup was heavily and improperly applied. She had a delusion of having ‘died in spirit and being reborn. She was markedly ambivalent and stated ‘I am not a fool; I am a fool. Delusions of persecution, particularly “sexual persecution,’ were present, and delusions of grandeur were prominent. She had a visual hallucination of “seeing babies in their mothers’ arms with their fathers present.” The history disclosed that the patient’s mother had died when she was 5 years old; her father had raised her alone. She felt pressure from her father to achieve; he would tell her “you have to finish school and be somebody.” She had worked hard in school, achieved good grades. and during high school had worked part-time. As a result, her social life had been limited; she did not date until she was 19 and then only occasionally until the year she became pregnant. She became heavily involved with two men that year and was not sure which man had fathered the child. In the hospital, she was treated with halopenidol and experienced rapid and complete remission of symptoms. She was then able to talk about her profound guilt over both the preg‘

‘

‘ ‘

‘

“

‘

Violent BY

JANET

Dyscontrol S. RICHMOND,

Responsive J.

RICHARD

AND

RESEARCH

REPORTS

nancy and the abortion. Over a 4-week period she was to work through many of her feelings, was discharged, returned to work. She continues in outpatient follow-up has

had

no further

psychotic

able and and

symptoms.

Discussion

Even in our contemporary society, with relaxed sexual mores and widespread therapeutic abortion, some individuals do feel guilty about abortion. One may attempt to rationalize, intellectualize, or otherwise defend against the guilt, but one cannot escape one’s superego. We suggest that psychiatric difficulties following abortion do occur and that physicians may be somewhat reluctant to recognize that a “therapeutic” procedure may produce morbidity. REFERENCES 1. Patt SL, Rappaport RG. Barglow P: Follow-up of therapeutic abortion. Arch Gen Psychiatry 20:408-411, 1969 2. Ewing IA, Rouse BA: Therapeutic abortion and a prior psychiatric history. Am I Psychiatry 130:37-40, 1973 3. Osofsky ID, Osofsky Hi: The psychological reactions of patients to legalized abortion. Am I Orthopsychiatry 42:48-60, 1972 4. Werman DS, Raft D: Some psychiatric problems related to therapeutic abortion. NC Med J 34:274-275, 1973 S. Lask B: Short-term psychiatric sequelae to therapeutic termination of pregnancy. Br J Psychiatry 126:173-177, 1975

to d-Amphetamine YOUNG,

M.D.,

AND

The psychiatrist will view a patient’s request for amphetamines with suspicion, especially if it is demanding, manipulative, or evasive. Many patients with pensonality disorders come to outpatient settings in search of drugs to abuse, and the standard answer to such a request is a flat “no.” However, the growing emphasis on an association of serious adult behavior disorders with a history of minimal brain dysfunction (MBD) in childhood (1-3) places the physician in a diagnostic and therapeutic dilemma: Patients with The authors are with the Psychiatry Walk-In Clinic, Boston Veterans Administration Clinic, 17 Court St. , Boston, Mass. 02108, where Ms. Richmond is Associate, Dr. Young is Resident in Psychiatry. and Dr. Groves is Coordinator. Ms. Richmond is also a student at the Simmons College School of Social Work; Dr. Young is Clinical Fellow in Psychiatry, Tufts University School of Medicine; and Dr. Groves is Clinical Assistant in Psychiatry, Massachusetts General Hospital, and Clinical Instructor in Psychiatry, Harvard Medical School. Address reprint requests to Dr. Groves. The authors wish to thank Leon Eisenberg, M.D., for intelligent vice and support during the treatment of this patient.

ad-

Opinions expressed herein are those of the authors and do not necessarily represent those of the Veterans Administration. 0002-953X/78/0003-0365$0.35

JAMES

E. GROVES,

M.D.

“adult brain dysfunction’ (ABD) (2), on MBD of adulthood (3), may respond to imipramine on to d-amphetamine, methylphenidate, or pemoline. These drugs may lead to improvement in impulse control and in the disordered attention fundamental to MBD (4) (which may have its basis in abnormal CNS “amousal” [3, 5]). Is the patient a drug abuser-or has he stumbled onto the sovereign remedy for his ABD? In our experience, the na#{239}ve report ofa calming or “paradoxical” response to stimulants, coupled with a history of impaired concentration and poor school and so‘

cial

functioning,

Case

Report

may

resolve

the

dilemma.

A 30-year-old married construction worker came outpatient clinic demanding ‘Desoxyn-or I’ll explode. the only thing that calms me down.” His wife, a large ‘

an

with

a scar

on

her

neck,

corroborated

his

story

to an It’s

womof

a

marked calming effect of methamphetamine, which he had obtained illicitly. Without it, he reported that at least once a week he had a sense of growing tension, a vague physical sensation of “pressure” and impending explosion. Then he would smash furniture or strike family members or stran-

© 1978 American

Psychiatric

Association

365